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Acute severe ulcerative colitis as defined by Truelove Witt’s criteria is a medical emergency which requires hospitalization. Patient requires close clinical monitoring with assessment of daily vital parameters, stool frequency, serum electrolytes and daily abdominal examination. Intravenous corticosteroids are the mainstay of therapy. Approximately two thirds of patients will respond to steroids. Response to steroids should be assessed at day 3 of admission and partial/ non-responders should be considered for alternative medical therapy/ surgery. Medical rescue therapies include intravenous cyclosporin and infliximab.This article provides an time bound step up algorithm for management of acute severe ulcerative colitis.